National Health Insurance (NHI) Bill: public hearings day 1

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18 May 2021
Chairperson: Dr S Dhlomo (ANC)
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Meeting Summary

Video: Portfolio Committee on Health

NHI: Tracking the bill through Parliament

In this virtual meeting, the Committee held public hearings on the NHI Bill. Five organisations presented oral submissions.

All the entities welcomed initiatives to improve access to quality health care services to all South Africans and proposed a number of amendments to improve the Bill.

The Health Professions Council said that the National Health Insurance (NHI) should be the only funding mechanism for health in the Republic; NHI should be funded through tax of all employed South Africans; private medical aid schemes may continue to exists but funded separately over and above tax paid for the NHI; for NHI to succeed health must be an exclusive national competence and that any section(s) of the Constitution that militate against this view must be amended; the Medical Schemes Act must be amended to ensure alignment with the NHI and NHI should be about funding and contracting while service provision is left to other entities, public and private

The Board of Healthcare Funders identified several constitutional issues in the Bill that might impede the implementation of NHI. These are:
- legal certainty and the rule of law – this relates to the language used in the bill
-restrictions on the right of health professionals to choose and practice their profession
-restrictions on the right of access to health care services in the bill, including the role of medical schemes to offer parallel benefits cover
- the role of provinces and municipalities, the second and third spheres of government in our constitutional system, in health service delivery

It proposed that Bill needs to be strengthened in several aspects:
- the language used in the legislation
-the constitutional issues raised by the Bill
-corporate governance of the NHI fund
-flow of funding from the fund to providers
-the role of provincial and local government in the delivery of health care services
-maintenance of the purchaser/provider split throughout the national health system

The Committee highlighted the severe shortage of nurses across provinces, as a result of funding cuts. Members asked how the situation could be rectified and how it would affect national health insurance. The Committee requested figures relating to the number of nurses across the country.

The Committee sought clarity from some of the entities whether they supported a single payment system or fragmented multiple payment systems with many private medical schemes; .what accountability mechanisms they proposed; if there are any other legislative changes that would need to be made within the national health insurance environment and their experiences in implementing universal health coverage in other countries.

Meeting report

The agenda of the meeting was adopted.

Opening Remarks
The Chairperson stated that the Committee would listen collectively to what the presenters have to say. No questions would be allowed outside the content of their presentations. Questions of understanding could be asked.

South African Nursing Council (SANC) presentation
Dr Raesetja Molepo, Chairperson, SANC, presented to the Committee on behalf of the South African Nursing Council (SANC).

SANC welcomed initiatives to improve access to quality health care services to all South Africans. However, SANC proposed a number of amendments to improve the Bill.

Inputs per section
-Section 15: Functions and Powers of the Board. Subsection (3)(e) and (f): They proposed that this should be functions of the CEO to report to the Board.
-Section 39: Accreditation of service providers: Subsection 2(a) only certain categories of nurses may run a private practice. Regulations are in progress then a nurse will have to have such a certificate and not a registration certificate (Annual Practicing Certificate).
-Section 40: Information Platform of the Fund. Subsection (4), they propose that beside the exception in 4(a)-(f), only the user may disclose.
-Section 42: Complaints and Appeals. Subsection (2), 30 days seems very short taking into account it may need a site visit and the obtaining and perusal of medical records – we propose 60 to 90 days. Subsection (4)(a) refers to only if a health care provider complains that they propose that the health care user be considered and does not include a user as in subsection 3 above.
-Section 44: The Appeal Tribunal is fully supported. The SANC has a similar appeals committee appointed by the Minister on an ad hoc basis. The Fund will need more than one appeals committee on a pool of members appointed on an ad hoc basis. Once the user and providers discover this ‘free’ service it will be used excessively.
-Section 45: Powers of the Appeal Tribunal. We propose to add the power of the Committee to award a cost order to prevent abuse of the process.
-Section 46: Secretariat. It reads Chief Executive of the Board, it should we proposed that it read be of the Fund.
-Section 57: Transitional Arrangements. Subsection (3)(a) the SANC regulates nursing education and could thus contribute greatly to such a committee. Subsection (4)(h)(ix) The Bill does not propose any reform or amendments to the Nursing Act 2005 (Act 33 of 2005, there is an ongoing process to amend the Act, and proposal by the Fund or the Bill can be included therein.

Definitions to be included in the bill
-Emergency Medical Treatment should be defined so that there is a common understanding

-Emergency Medical Services should be re-defined as Emergency Health Services in order to include emergency health services provided by all health professionals, doctors, allied health practitioners, including nurses.
-Healthcare Professional should be defined to mean any persons registered with the health statutory councils in South Africa
-Primary Health Care Nurse should be as defined by SANC; a professional nurse capable of providing direct patient care for all types of illnesses and ailments, offering first level of nursing care and is competent to independently render appropriate and skilled primary care service.
-Primary care nursing professional is a category not recognised by SANC and must be removed. 

Recommendations per chapter

Chapter 2: Asylum Seekers
-Emergency Medical Services should read Emergency medical treatment in terms of the National Health Act

Chapter 6: Constitution and Composition of the Board

-Clause 5: the composition should be clear to include expertise in health care services provision, and health care service financing. As the NHI fund is a health fund it should include persons with expertise in health services provision.

Chapter 7: Advisory Committees
-Clause 25.2: Membership of the benefit advisory board should include technical expertise in nursing and pharmacy as these professions are at the frontline of NHI programme implementation in the context of Primary Health Care Engineering, and are not represented by medicine.

Repeal and amend legislation affected by the Act
The Nursing Act, 2005 (Act No. 33 of 2005) should be listed in this section for amendment.
-The promulgation of Regulations for private nurse practice is underway and professional nurse practitioners will offer services through contracting for management of health conditions within their competencies and scope of practice.

Memorandum on the Objects of the National Health Bill Services 
Clause 4.4.1. The PHC outreach team led by a nurse will be deployed in each municipal ward.
-The term “supported by the nurse” should be deleted and replaced by “led by the nurse” as nurses are the primary health professionals in the first level of the health system and should be empowered to lead the PHC outreach team for quality and patient safety.

(See Presentation)

Ms E Wilson (DA) stated that the Committee had established that there was a severe shortage of nurses when it went to the various provinces. It was not that nurses were not available. The funding that was cut from departments had resulted in too few nurses – this was the case in the Northern Cape which the Committee had visited the week before. Nurses were the crux of the health system; it was a huge problem if there were not enough nurses. Without them they were unable to effectively service the sick and the vulnerable. She asked how they thought this could be rectified and how it would affect National Health Insurance (NHI).

Mr T Munyai (ANC) highlighted that he had struggled to get the original documents that were put in the system and requested that they be emailed to the Members, particularly the summary of the presentation and related documents. In relation to the presentation, he asked whether the organisation supported the NHI? He requested clarity on this.

Dr Molepo acknowledged the shortage of nurses. She asked her colleague to respond in terms of the strategies that the Council had put in place to assist provinces, in terms of the shortage of nurses.

Ms Sizo Mchunu, Registrar and CEO, SANC, stated that SANC fully supported the Bill and was right behind government in that regard. In terms of the shortage of nurses, the role of a statutory body was to support government in a variety of ways. They saw themselves as providing information – as they were the custodian of the register for nurses. They provided information to the National Department of Health in respect of the number of nurses, the category of nurses and the specialist nurses they had on the register. The Council had developed competencies for the scope of new nurses. They saw themselves as assisting government in terms of identifying the categories of nurses needed, particularly with respect to primary healthcare. The Council stood ready to assist the colleges that were meant to train nurses. They assisted with the curriculum design and processes of accreditation when colleges put their educational programmes together. The Council had sourced and stood ready with extra temporary resources – should they be overwhelmed with applications coming from government institutions that needed to train nurses within NHI. They would circulate information regarding NHI to students, educational institutions and health facilities. They had a database of all stakeholders that included the unions. There were a variety of ways in which they could engage.

The Chairperson asked what the number of registered nurses was on their database across all the categories in the country.

Ms Mchunu replied that the gross number of nurses was 285 000 across all categories.

Mr A Shaik Emam (NFP) stated that given that there would be an impact on the nursing fraternity, to ensure the success of NHI, was the Council engaging with other relevant departments, such as Health and Education so as to try introduce nursing as a part of the curriculum for grades 10, 11 and 12. He suggested this would promote and encourage students to enter nursing with the passion it required.

Ms Mchunu stated that SANC had not physically gone into any high schools but it had material that it had shared through magazines as well as on their website that provided information to school leavers. It provided information relating to nurse training as a career. The Council published a list of accredited nursing education institutions together with the programmes that they respectively ran, the province where they were located, and the relevant entrance requirements. A campaign was started and the National Department of Health was assisting them in this regard. The hashtag was ‘#bethatnurse,’ the campaign was not meant for high schoolers only – it was meant for those who were already in nursing. It was intended to encourage them and re-instil a sense of pride in nursing so that they could motivate others to also become nurses.

The Chairperson suggested that the Council visit the Nursing College of the Northern Cape. The Committees had gone there. The Nursing College had experienced a number of challenges – he suggested that the Council get in-touch with the leadership of the Nursing College.

Ms Mchunu stated that they would do so.

South African Pharmacy Council (SAPC) presentation
Mr Mogologolo Phasha, President, and Mr Vincent Tlala, COO, presented to the Committee on behalf of the SAPC.


Pharmacy has been omitted from the definition of primary health care. Pharmacy is vital to primary health care. A Pharmacy is more often the first level of contact with a patient, or care giver with the health system.

SAPC Recommendation: insert “pharmacist” and “Primary Care Drug Therapy (PCDT) pharmacist”

Chapter 7 – Advisory Committee established by the Minister

The SAPC welcomes and supports the inclusion of persons on such committees, as detailed in Chapter 7, based on expertise in medicine. The SAPC trusts that such expertise does in fact include experts in pharmacy.

In this regard, the SAPC assumes that “medicine” as it is included herein pertains to the definition of medicine as provided in the Bill.

In addition, it should be noted that a pharmacist is an expert in medicine, as their qualification of a Bachelor of Pharmacy includes five core modules named pharmacology, pharmaceutical chemistry, pharmaceutics, clinical- and social pharmacy which constitute around 70% of the total curriculum.

Pharmacists are trained on the holistic approach to medicine, from molecular development to medicines’ impact on a patient’s health.

Further, the SAPC looks forward to contributing to such Advisory Committee provided for in Section 27.

Chapter 8 - Section 38
-Section 38, under the title “Office of Health Products Procurement” opens with the statement that the Board must establish an Office of Health Products Procurement which sets the parameters for the public procurement of health-related products, and in Section 38(2) it goes on to qualify, stating the procurement of health-related products, including but not limited to medicines, medical devices and equipment.
-The SAPC states that the statement above is contradiction to the definition of health-related products, which expressly excludes “orthodox medicine”.

SAPC Recommendation: (a) There is a need to revisit the definitions of health goods and health related products and their use throughout the NHI Bill, especially Section 38 which is where the definitions are most critically used. Once again, the SAPC moves for the recommendation that the definition of health related products be removed from the Bill, and that it be replaced with health goods or health products, with the preference for health products as this is the internationally accepted term as used and defined by the WHO.

SAPC Recommendation: (b) In terms of Section 38(3)(d), the current wording provides for the Office of Health Products Procurement to “facilitate the cost effective, equitable and appropriate public procurement of health related products on behalf of users”.

It is recommended that the WHO definition for “promoting affordable and fair pricing and effective financing” which states “equitable access to essential, high-quality and affordable essential medicines and other medical technologies depends on affordable and fair pricing and effective financing schemes”, be used as in line with international benchmarking, including the words “cost effective”, and to sure that the health products procured address not only cost, but also quality and effectiveness.

Chapter 8 - Section 39
Section 39, under the title “Accreditation of services providers”, and in particular Section 39(2)(b) states that service providers must comply with the prescribed specific performance criteria, which includes inter alia the minimum required range of personal health care services and allocation of the appropriate number and mix of health care professionals.
Although no mention is specifically made of primary health care, but rather a broad mention of a minimum required range of personal health care service, the SAPC wishes to express concern that the absence of pharmacy under the definition of primary health care could limit, if not exclude pharmaceutical services being provided by pharmacies.
This is further highlighted by Section 37 under the title “Contracting Unit for Primary Health Care”, which by definition would exclude pharmacy from the contracting for primary health care services.
Another example of potential exclusion for pharmacy is contained in Section 41, under the title “Payment of health care service providers”, and in particular Section 41(3)(a), following on from Section 37, where it states that only accredited primary health care service providers must be contracted and remunerated by a Contracting Unit for Primary Health Care.
-The SAPC wishes to recommend caution the Minister in terms of duplicating functions by the proposed National Health Insurance Fund, the Health Management Offices and the Contracting Unit for Primary Health Care, in the accreditation of service providers and the potential investigation of complaints.

Chapter 9 – complaints and appeals
-Under Chapter 9 of the NHI Bill, the SAPC main comments ate on section 44(1)(a); section 46; and section 47(3).
Section 44(1)(a) which reads, “One member appointed on account of his or her knowledge of the law, who must also be the chairperson of the [Board]” should have the word “Board” replaced with “Appeal Tribunal”.
- On Section 46 of the Bill, the SAPC recommends that the NHI Bill should have the word “Board” replaced with “Fund” and the second mention of the word “Board” replaced with “Appeal Tribunal”
Section 47(3) provides that the Appeal Tribunal must determine the outcome of the appeal within 180 days. SAPC is of the opinion that 180 days is somewhat excessive, and proposes that an appeal should be concluded within 90 days.
-In supporting the proposal of 90 days for the appeal to be concluded, SAPC states that given the nature of the business of the Fund, in terms of the fact that the appeal may be by a user who requires health services under the Bill in an emergency. Furthermore, the delay in paying a health care provider or refusing accreditation to a health care provider that may delay the provision of health care services.

(See Presentation)

The Chairperson requested clarity as to whether the entity had any women represented on the Board or in the employ of the Pharmacy Council.

Ms Wilson expressed that she was glad to hear that there were up to five pharmacies in a village – whereas in villages in Limpopo, pharmacies seemed to be non-existent. One of the primary issues on the NHI Bill was that there would be a centralised purchasing system – this could go a lot of ways – it could go well or very badly. If medical or pharmaceutical suppliers were put out to tender – there was potential for abuse of the system where there would be competitive price cutting which would affect the pharmaceutical industry very badly. This would become a huge restriction on a lot of their suppliers, regardless of whether it was medicine, medical supplies or equipment. She asked whether they had considered that.

She noted that the SAPC had highlighted sections of the Bill that it wanted to see amended and that it supported the Bill – she requested clarity as to whether it was supporting the Bill as it was or only on the condition of the inclusion of the amendments.

Ms S Gwarube (DA) referred to the expansion of the provision of primary healthcare. She agreed that the definition of primary healthcare should be broader than its definition in the Bill. How did the Council envision the provision of primary healthcare? Under an NHI environment - were they hoping to expand the provision of pharmaceutical services, understanding that they now had the provisions of immunisations, contraceptives and the like? She wanted to understand their ‘envisioned role,’ as a key player in the provision of primary healthcare in the NHI environment. This was linked to a comment that was made around the fact that increasingly pharmacies were based in rural areas and townships. Perhaps that was happening – but that was at a very limited scale. If they wanted to expand the provision of primary healthcare, where were they looking to go with pharmaceutical services – what kind of services were they wanting to provide under the Bill should it be passed in its current form?

She asked for further clarity regarding the amendments to the Medicines and Related Substances Act, what substantive changes were they looking to see made? Obviously one of the big things around passing a Bill of that nature was that it had a ripple effect on other pieces of legislation which would potentially need to be changed. She echoed Ms Wilson’s point about having a broader footprint – but was this what they wanted to see in a Bill of this nature? If so, what was stopping them from doing it now – regardless of whether or not the Bill was passed.

Mr Munyai requested clarity as to whether the organisation supported the NHI Bill or not. Did the pharmacists not regard themselves as part of the health team? Nowhere in the Bill were specific health categories described in detail – why did they want to be treated differently from other professional organisations? Why was the Pharmaceutical Council regulating practitioners for practicing telemedicine in their pharmacies? Why would they want to creep in on the mandate of Health Professions Council of South Africa (HPCSA)?

Ms A Gela (ANC) asked, if the Council supported the NHI Bill – could they indicate to the Committee, how many pharmacists they were representing.

Dr K Jacobs (ANC) noted that the Council was driving a particular point home – and that was the exclusion of pharmacists from the definition of primary healthcare. They were also driving the view on their role in the health system. How did they see themselves playing a role, as pharmacists, within the NHI programme?

The Chairperson stated that there was a decision taken, because of the scarcity of pharmacists in the country, especially in the rural areas – to expand to include ‘pharmacist assistants.’ He asked whether SAPC could indicate what the specific value add of the pharmacy assistants was, in light of the expansion of the category of healthcare professionals. Where were they located – how many had they developed in the country – did they still want this to be expanded?

Mr Phasha replied that SAPC supported the Bill with or without the amendments. SAPC believed that the proposed amendments would enhance the Bill. In terms of the expansion of the role that pharmacists played - the scope of pharmacists today – had expanded so much in comparison to what pharmacists used to do 30 years before. The Pharmacists Initiated Therapy (PIT) was when a patient walked into a pharmacy and explained their condition and the pharmacist would recommend specific medication. That was the provision of primary healthcare in terms of ailments that people suffered. In terms of the expansion of pharmacists roles, they were now able to recommend therapy to patients who were on antiretrovirals (ARVs).

SAPC did not feel that pharmacists needed to be treated differently. In the Bill where it referred to ‘primary healthcare,’ it made mention of the general practitioner (GP) and the nurse – they were requesting that pharmacists be added to that section. It was not that they wanted to be the only profession mentioned, but various others had been mentioned in terms of primary healthcare.

In terms of the scope of the Council, there was no intention for the Pharmacy Council to encroach on the Health Professions Council’s mandate. They worked closely with the Health Professions Council and had recently completed a Memorandum of Understanding (MoU) with them.

The Pharmacy Act was not the only thing that spoke to their scope or mandate – the Medicines and Related Substances Act applied to them. There was a reliance on the Medicines and Related Substances Act in terms of what they did and the regulation of professional pharmacies. The ‘pharmacy technician’ was a new role that was introduced after that of the pharmacist’s assistant. The aim was to ensure that they increased the number of people who could assist the pharmacists. They had different expertise because of their training. It was almost impossible for a pharmacist to run a pharmacy without a pharmacist assistant. The pharmacy technician or pharmacist’s assistant was responsible for a lot of the menial work that took place in the pharmacy. The pharmacist could then continue to advise the patients, doctors or other members of the health team that the pharmacist worked with. 

Mr Tlala addressed the questions regarding the pharmacy support personnel. They saw both the pharmacist assistant and pharmacy technician in primary healthcare. He noted that there were approximately 4000 facilities in the public sector – some did have pharmacy technicians. They played a fundamental role and addressed issues such as shortages in the clinics. Nurses were currently overloaded, pharmacist assistants and pharmacy technicians were often based at clinics to assist in terms of primary healthcare management. There were presently 24 598 pharmacist assistants and 18 678 pharmacy technicians.

They collaborated with the Health Professions Council and did not intend to take over their mandate. There were often clinics within pharmacies to assist with various tests (i.e glucose tests) and nurses often operated in these clinics. If a pharmacist was of the opinion that a patient needed to be seen by a doctor, the patient did not have to walk nor travel to the doctor – ‘telemedicine’ could be used. They could contact the doctor whom could diagnose and prescribe treatment via telemedicine. This was part of their ‘one-stop approach.’ They wanted to get to a point where patients did not have to run all over the show to get treatment. There were people, who after doing a two-year diploma in primary care were able to prescribe schedule 3 and 4 medicine. They were issued a permit from the Director General as part of primary healthcare services. They mainly looked at minor ailments – like tonsillitis and continued with services relating to the management of chronic medicines. Pharmacies were also starting to assist with immunisations.

He referred to the Bill where it stated: ‘In the private healthcare sector, there was the GP, primary care nursing, primary care dental professional and primary allied professional.’ The other professions were specifically mentioned in the Bill, that was why they had proposed that pharmacists should be included as well. When they had asked about this, they were told that pharmacists were ‘primary allied professionals’ – pharmacists were not. It was important that the omission was corrected when the Bill was officially published.

When it came to pricing, because of the volumes that government procured in comparison to the private sector, there was a disparity – NHI would also bring about equity in terms of the pricing. The cost differentiation between sectors was huge – that was why they supported the universal healthcare approach.

In terms of the Medicines and Related Substances Act, the ‘authorised prescriber’ referred to in the Act currently excluded pharmacists. As the Bill was being processed, there was a need to change the Medicines and Related Substances Act to reflect that pharmacists were also authorised prescribers.

Mr Phasha stated that they did not represent pharmacists, they registered all pharmacists in the country. If a person with a BPharm degree was not registered with the Pharmacy Council, they would not be able to call themselves pharmacists. One only became a pharmacist upon registration with the South African Pharmacy Council.

Ms Mojo Mokoena, Registrar and Senior Manager: Professional Affairs (Practice), SAPC, provided numbers relating to their register. There were just above 16 500 pharmacists, 18 000 pharmacist support personnel (she had excluded the students that would be on first, second and third year internships – those registers were monitored). They were preparing for the expansion. They had engaged with accredited providers – as they were their key stakeholders to ensure that they increased training so that when they got to the point of NHI they were ready as a profession. They had also looked at revising the mission of the South Africa Pharmacy Council, which was done with the inception of the new Council. This included the elevation of universal health coverage to ensure that the work that they did on a daily basis supported the achievement of NHI. In terms of the pharmacy technician – their sights were on what an ‘ideal’ clinic might look like.

The Chairperson stated that they had become aware of the rurality of certain clinics and support of primary healthcare providers.

Mr Munyai stated that the context was that they were allowed to diagnose, prescribe and dispense. Clarity was therefore requested regarding the regulation of telemedicine and the respective mandates– of HPCSA and the Pharmacy Council.

The Chairperson replied that this question was previously answered.

Mr Munyai pointed out that the entity had failed to clarify on its mandate. He requested a response to his specific question. The response previously given did not answer his question.

Mr Phasha stated that the entity was not regulating telemedicine. In the expansion of the scope and role of pharmacists, he had tried to illustrate that pharmacists now offered services such as telemedicine. Pharmacists’ roles were not limited to primary healthcare – telemedicine had offered a way to extend this. They only regulated the pharmacy itself and how it worked. Telemedicine was an addition where the doctor remained under the Health Professions Council.

Health Professions Council of South Africa (HPCSA) presentation
Prof. Mbulaheni Simon Nemutandani, President, and Prof Nathaniel Mofolo, Council Member, presented to the Committee on behalf of the entity.

The Council welcomes the National Health Insurance for the following reasons:
- Health equity and social justice
- Reducing inequalities between the public and private sectors
- Ensuring quality assurance for universal health coverage
- Enforcing Professional Codes of Conduct and Ethics
-Enhancing the Human Resources for Health as the key component and driver of universal coverage for health by ensuring that there are adequately qualified professionals trained and registered that meet the needs of the country by effectively carrying out its mandate of providing for control over the education, training and registration for and practising of health professions registered under the Act.

Views about National Health Insurance
-The National Health Insurance (NHI) should be the only funding mechanism for health in the Republic. 
- NHI should be funded through tax of all employed South Africans
- Private medical aid schemes may continue to exists but funded separately over and above tax paid for the NHI
-For NHI to succeed health must be an exclusive national competence and that any section(s) of the Constitution that militate against this view must be amended. 
- The Medical Schemes Act must be amended to ensure alignment with the NHI. 
- NHI should be about funding and contracting while service provision is left to other entities, public and private

Proposed Specific Amendments to the Bill
-Clause 6(o) Rights of Users: To pay through out-of-pocket means, health care services that are not covered by Fund  
- Clause 8 Cost Coverage: A person or user as the case may be must pay for health care services of that person or user:  
-Clause 8(b) Cost Coverage: Delete Clause 8 (b) 
-Clause 11(h) Powers of the Fund: Investigate complaints against Fund, health care providers, health establishment and suppliers in collaboration with law enforcement agencies, statutory councils, and regulatory authorities 
-Clause 13(6) Constitution and Composition of Board: The CEO, CFO and Chief Actuarial Officer are ex-officio members of the Board but may not vote at Board Meetings 
-Clause 33 Role of Medical Schemes: The future role of medical schemes will be to offer complementary coverage to services not covered by NHI as determined by the Benefits Advisory Committee. The Minister will determine through regulations in a gazette when this phase will ensue.
- Clause 34(3) National Health Information System: Health Workers, health care service providers and persons in charge of health establishments must comply with provisions of the National Health Act and provisions of Section 40 of this Act relating to access to health records and the protection of health records 
-Clause 44(a) Appeal Tribunal: Remove the word Board at the end of sentence 

(See Presentation)

Mr Munyai highlighted that in the presentation it was stated that the NHI must be the only funding for healthcare services. In subsequent slides, it was stated that the private medical scheme must coexist with NHI – was this not a contradiction? It was stated that the entity supported a single-payment model – what was the real position of the HPCSA? They wanted clarity not confusion. Did it support a single payer, a single fund or fragmented multiple payment system with many private medical schemes?

Ms Gwarube sought clarity regarding the comment that was made around the management of the Fund, especially when it came to funders being both the referee, player and the like. What was the position of the HPCA? With respect to the accountability mechanisms, what did the HPCA envision should be the accountability mechanisms built into the management of the Fund? Clearly there was concern regarding oversight mechanisms. That was not expanded upon when that point was made. It was a very important point to make. She requested clarity on what the HPCA envisioned as an appropriate accountability mechanism when it came to the management of the Fund.

Dr Jacobs stated that he had not heard HPCSA speak much about the responsibilities toward the healthcare professionals whom they represented. They heard earlier from the Pharmacy Council about what their role ought to be in the future in terms of the NHI. Did the HPCA see itself having a different role or did it see itself having to contribute to improvements of regulations with regards to the healthcare professionals who registered with them.

Mr Gwarube asked an additional question. Did the Council foresee any legislative amendments that would need to be made in an NHI environment?

The Chairperson stated that the HPCSA represented 12 Boards. He suggested that there was a Board that felt that it was getting a bashing or being ill-treated – as it was seen as a ‘bigger brother.’ He encouraged the HPCSA to really deal with those issues. It was outside of this discussion – he did not think the entity needed to address the issues during the meeting. The Committee did not want to see a situation where there would be a split – he asked that they address those issues.

Prof Nemutandani stated that the entity welcomed the comments and advice. It would like to engage with the Chairperson’s office on those issues. The HPCSA wanted to put it on record, that for NHI to work, there needed to be only one funding mechanism for health in South Africa. It was essential. It should replace all funding mechanisms for health. All assets that ceded under medical schemes should be transferred to NHI – that was the position of HPCSA. For NHI to succeed, there needed to be an exclusive national competency; any section of the Constitution that was ‘against this view needed to be amended.’ The NHI Bill should repeal the Medical Schemes Act in its entirety, as it had no place in the nationalised, centralised funding for health. Any person who required extra insurance, or cover, would have to apply under the Insurance Act. There should be no question about those issues. South Africans needed to have access to health, irrespective of whether they were domestic workers, CEOs or Board Members. The first thing that was checked after a car accident was whether the patient had medical aid – irrespective of the condition of the patient. It should not happen in the new South Africa, 25 years after democracy. They needed to take responsibility in ensuring their people had access to health services.

Advocate Phelelani Khumalo, Head: Legal & Regulatory Affairs, HPCSA, addressed the issue of why the entity was of the view that the funds should not be the referee nor the player. It stemmed from the fact that service providers were separated from the payer – so that investigations of any conduct of health practitioners as service providers should be left to the statutory boards who were concerned with that.

He clarified their role, they regulated health practitioners. The HPCSA ensured that every practitioner registered with them was competently educated and trained and remained competent throughout training. They would ensure that NHI only contracts practitioners that were competent and delivered quality healthcare to all. The HPCSA wanted to ensure that the much-needed specialists that the Country needed were being produced, as they set the standard of education and training. For NHI to succeed they needed those specialists to be in adequate supply. As the regulatory body of health professionals in South Africa, with a register of more than 200 000 practitioners, they needed to ensure that people recieved adequate and quality healthcare.

Following the recommendations by the Health Market Inquiry (HMI), the HPCSA had amended a number of rules that were rigid and restricted group parties – i.e sharing of rooms and sharing of fees had been amended.

Mr Lerole David Mametja, Head: Core Operations, HPCSA, stated that the Council was based on a very old Act of 1974. There had been some amendments along the way; there had been other legislative developments outside the space in which the HPCSA functioned. There had been instances of duplication or lack of clarity regarding respective roles of the HPCSA and other entities, such as the National Qualifications Framework. HPCSA started a legislative review process that was instigated by previous Council. Ultimately it would be Parliament that would make a determination on these matters. That process was intended to reconcile areas of difference and address legislative gaps. The NHI was still under development. Legislatively, once firm decisions were made, there would be a need to reflect on the implications of the NHI – across all role players functioning in that space.

Prof Nemutandani stated that, as they were having a single funding system, there should be consideration of having a single health regulatory body in South Africa. All stakeholders would have a role on the single funding system. It was upon the Committee to consider having a single regulatory body. There were various bodies; there was no ‘big brother’ or ‘small brother.’ The success of the single funding system hinged largely on two aspects that were within their control. Production of competent appropriately trained people to manage services at different levels and a regulatory system that was able to make sure that the training was aligned to South African needs.

Board of Healthcare Funders (BHF) presentation
Dr Katlego Mothudi, Managing Director, Ms Michelle Beneke, Company Secretary, and Charlton Murove, Head of Research, presented to the Committee representing BHF.

BHF Supports UHC:
BHF supports the concept of universal health coverage (UHC) as defined by the World Health Organisation (WHO), i.e. ‘Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship’.

Constitutional rights:
- The NHI Bill must be constitutional, not only in its provisions, but also in its approach to health care financing.
- The financing system that the bill creates must recognise and respect the constitutional rights of individuals to have access to health care services.
- It must reflect the government’s commitment to protect, respect, promote and fulfil this right, along with the other rights in the Bill of Rights.

Constitutional issues in the Bill:
BHF has identified several constitutional issues in the Bill that might impede the implementation of NHI. These are:
- legal certainty and the rule of law – this relates to the language used in the bill
-restrictions on the right of health professionals to choose and practice their profession
-restrictions on the right of access to health care services in the bill, including the role of medical schemes to offer parallel benefits cover
- the role of provinces and municipalities, the second and third spheres of government in our constitutional system, in health service delivery

The NHI Bill needs to be strengthened:
- the language used in the legislation
-the constitutional issues raised by the Bill
-corporate governance of the NHI fund
-flow of funding from the fund to providers
-the role of provincial and local government in the delivery of health care services
-maintenance of the purchaser/provider split throughout the national health system

Accountability – NHI Fund:
-BHF is of the view that the NHI Fund must be accountable at three different levels in order to ensure its sustainability and viability.
-The Fund must be accountable to Parliament at a macro level, secondly the Fund must be accountable to the Minister of Health in accordance with the Public Finance Management Act and thirdly the Fund must be accountable to the Prudential Authority for financial institutions created by the Financial Institutions Regulation Act that sits within the Reserve Bank.
- The Prudential Authority should serve as an overseer of the Fund in order to ensure that its financial risks and affairs are conducted properly and in accordance with independently determined standards.
-The Public Finance Management Act, although it applies to the Fund, only regulates certain aspects of the Fund.
-There is a gap which we submit must be filled by the Prudential Authority which has the skills and expertise to provide oversight of the fund’s financials.

Language used in the Bill:
-The bill uses policy language that makes legal interpretation difficult. The language is imprecise and open to different interpretations.
-There are several unnecessary repetitions. The transitional arrangements section belongs in policy documentation, not law.
-There are specifics in the bill such as reimbursement models the fund will use to purchase health services that belong in regulations.
-There are sections of the bill that belong in the National Health Act (NHA) and not the Bill.
-The latter should be purely about the financing side of the purchaser/provider split.
-It should not contain provisions that relate to the organisation, structure and methods of health service delivery.

-The Bill does not adequately explain the reason for district health management organisations (DHMOs) or contracting units for primary care (CUPHCs).
-It also does not set out their role, how they will be governed and to whom they will be accountable.
-BHF is of the view that DHMOs and CUPHCs are unnecessary and will add an unjustifiable layer of administrative costs to the system.

The role of the Minister of Health:
-BHF does not support the extensive role of the Minister of Health as set out in the Bill. The board of the fund must be autonomous and independent of political influence in its decisions.
-The board must have complete authority over and responsibility for the fund.
-The board must run the fund – not the Minister.
-The Bill gives the Minister the power to potentially veto every significant decision that the board can make. This means that the board cannot be held accountable for its decisions. This is contrary to well-established principles of corporate governance.
-The board must not be able to escape accountability as a result of a decision by the Minister.
-The Board must be accountable for all of its decisions.

Powers of the Board:
-The board must be free to hire or terminate the services of the CEO of the fund without the approval of the Minister.
- The board must be able to determine benefits to be covered by the fund without the prior approval of the Minister.
- The board should be appointed by Parliament and not the Minister because this guarantees a more open and democratic process.
-The board must play an active hands-on role in the running of the fund, so it needs to be a powerful executive Board that operates full time.
- It is accountable to the Minister in terms of the Public Finance Management Act (PFMA) but this does not mean it should have to obtain the Minister’s input on every decision it makes. Indeed, it can only be accountable to the Minister under the PFMA if it can make decisions independently of the Minister regarding the fund.

(See Presentation)

The Chairperson stated that it was unfortunate that what was being talked to was not reflected in the slides.

Dr Jacobs referred to the introduction of low-cost benefits for those employed, but not insured, not to undermine the principle of solidarity and perpetuate fragmentation in the funding. In terms of strategic purchasing, he requested clarity regarding their understanding of the principle which underpinned the NHI. His understanding was that the Bill stated that the NHI Fund would be established as a separate entity outside of the Department of Health.

He asked the presenters to indicate the clause in the Bill that said the NHI would be investing in private health facilities – and whether he had heard them correctly in this regard. When he read the Bill, he had assumed that the District Health Management Offices were to be established through amendments to the National Health Act, as contained in schedules of law to be amended – he requested clarity in that regard.

Mr Gwarube stated that right at the beginning of their presentation they had mentioned a number of entities that they worked with. She thought they had mentioned that the Namibian National Health Insurance worked with them. What were some of the pitfalls they had observed in rolling out universal healthcare in relation to their experience in considering Namibia, which had similar inequalities? They had mentioned a number of things, including the governance models, where they could be strengthened. It would be really interesting to hear practically where they had concerns – in terms of some of the entities they had worked with. They were keen to hear practical experiences – particularly with respect to countries that had similar socio-economic status to South Africa.

Mr Munyai stated that in the presentation it was quoted that the Minister had stated that over eight percent of the Gross Domestic Product (GDP) was spent on healthcare. This was more in line with an advanced economy. If they were to outline the Minister’s entire quote, and not selectively quote, it went further to state that good healthcare was not provided to everyone, there were many who did not get healthcare when they needed it. The Minister had stated that this was because the root of the problem could be traced to the two-tiered system of healthcare inherited from the apartheid era. What exactly was the mandate of the Board of Healthcare Funders? Are you a private industry regulator? How would they reconcile a pay-yourself NHI (not-outsourced)? With the constituency of the multiple payer medical scheme environment – in this context – how did they reconcile the role of the Board of Health Funders. Why did they say that public facilities would not be accredited? Could they indicate in their response where this was in the Bill? Where in the Bill did it refer to the issue of the sale of Panado? Could they assist by providing the exact clauses from the bill.

The Chairperson asked whether, as a result of their international experience and collaboration, they have a particular model they would promote in terms of universal health coverage? If so, he requested that they share it with the Committee or government.

Dr Mothudi explained that they had not put too many words on the slide as they had presented more comprehensively in their written submission. This was to highlight specific talking points and provide a graphical representation.

In terms of international experience, they would gladly share these. They should highlight that in their experiences in various countries, although they had similar challenges, there were some common threads. The issue around governance was internationally acclaimed. In their submission they had spoken about what could be done to augment the oversight role. In terms of there not being enough oversight – they had referred to multiple layers or what some people referred to as ‘dual-oversight.’ The role of Parliament and the Minister was significant. There was a necessity for an additional regulation – maybe from the prudential authority, the Reserve Bank for example. They were cognisant of the many touch points that were necessary for oversight.

The issue of the single payer – their interpretation was that in the way it was articulated it meant that nobody else was allowed to purchase any healthcare, other than the Fund itself. Ms Beneke had made an example – the Bill could outlaw practices such as Pick n Pay selling Panado. The Board of Healthcare Funders was a voluntary association; it did not control the organisations that were in its membership. It did play a role in terms of advising them on issues relating to healthcare policies and other services. It could take up industry issues on behalf of the entire membership. It represented healthcare beneficiaries who they referred to as ‘health citizens.’ The Council for Medical Schemes (CMS) was a regulator and for as long as medical aids existed, that was their role. The entity knew there were attempts to fortify the governance role through the Conduct of Financial Institutions Bill. That was a model that should be in place in terms of governing the Fund over and above Parliament and government oversight with the Minister – there was a need for some sort of prudential authority oversight.

Mr Murove stated that the low-cost benefit option had been looked at for a significant number of years, since the late nineties. It arose from the realisation that the current benefits excluded cover for a significant portion of the population who would like to use their excess funds to purchase healthcare only for purposes of family healthcare. The typical example that was often used was when someone had the flu and did not want to spend the whole day going to a clinic, and lose a day of work. They rather went to a GP to see if it was a serious condition or not so that they could get on with the rest of their day. This segment of the market could not afford to pay for cover that included hospitalisation, in which instance they preferred to use the State. The low-cost benefit option addressed market need which was real. Currently, the people who would be covered by this market do pay for healthcare through insurance, which was very fragmented and poorly regulated. This market was quite big the estimate was that it was more than three million people covered – but they were not getting the care that they needed. If they were brought into the medical schemes environment, there would be better oversight in an environment that was much more geared to provide healthcare and those people would be offered better protection. In terms of alignment with greater healthcare reforms, it was being reviewed to include family care. The inclusion of the low-cost benefit option would provide better alignment.

Dr Rajesh Patel, Head: Benefits and Risk, BHF, referred to the District Health Management Office as well as the caps to be included in the National Health Act. The problem was that it created an additional layer of health service provision and management. The Constitution already provided for the provinces and municipalities to provide services. From the perspective of the district health management and caps, one was creating a new management layer. If one introduced the caps, one was creating an additional layer of management; that was unnecessary – why not allow the provinces to contract directly with NHI – who already had the powers to provide services and accounts of those hospitals and clinics?

Strategic purchasing was making sure one paid for services that were associated with good quality. It was moving away from providing money and getting back ineffective care for that. It would be structured so that payment would be based on assessment of quality and outcomes. If one got good quality outcomes, the payments would follow through – there would be some tiered payments based on quality, whereby better quality would result in additional remuneration. He did not understand the link to the question raised by Dr Jacobs. He requested further clarity regarding the question and then he would respond.

The Chairperson stated that Members should consult the written document submissions. He then allowed Ms Gela to ask a question but requested that it be answered in writing due to the time constraints.

Ms Gela referred to the Constitutionality of the Bill – what was their view about section 27 of the Constitution, especially subsection (2). She referred to the section as a whole, in that everyone should have access to healthcare – what was their comment on that Constitutional imperative - in relation to their point on the Constitutionality issue.

Closing Remarks

The Chairperson asked that it be responded to in writing and they would start by communicating the response to the Committee the following morning during their next meeting. He briefly outlined the programme for the following day.

The meeting was adjourned.

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